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Based on observation and staff interview the facility fails to ensure that plan review is completed before starting construction projects. The failure to complete plan review before beginning a construction project can prohibit required egress and fire protection features from being maintained. This deficient practice affects all residents in 3 of 12 smoke zones on the second floor. The facility has a capacity of 58 residents with a census of 21.

During the survey on July 5 and 6, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. On July 5, 2017 at approximately 10:30AM no plan review has been completed prior to construction.

2. On July 5, 2017 at approximately 11:20AM the North exit corridors on the second floor have been eliminated by construction walls. These wall prohibit staff and patients from continuing down the corridor to the exit. This creates a dead end corridor of 176 ft.

3. On July 5, 2017 at approximately 11:30AM the construction walls dividing the 2nd floor project area from the patient area is not constructed to one hour fire resistance.



On July 5th 2017 at 10:30am at Via Christi St. Teresa Hospital it was discovered that the fire alarm panel was showing a trouble on the system. Maintenance tech A stated that there was a construction project being started that required them to remove smoke detectors from that portion of the hallway and that the system had been placed on test. The smoke detectors located in the corridor and interior rooms of the project area had been removed from their bases. During the presurvey on the facility there was no record of a construction project being performed. No plan review was performed for this project.The plans for the facility were then reviewed maintenance tech A described what was planned to take place for the new construction project and where the project was located.

When arriving at the project area on the second floor at approximately 11:20 AM it was observed that the corridors to the end of the North hallway had been terminated by a new wall constructed out of drywall and metal studs to prevent others from entering the construction area. These walls were not rated to one hour and eliminated the remote exit for the North and center smoke zones. One of the two corridor walls that had been constructed had a non-rated door as a pass-through door for the construction workers from the construction area to the patient care area.

The second floor is constructed of three smoke zones. One of those smoke zones located in the East portion is walled in with a rating of 2 hours. The other two zones are located in the center portion and the North portion. The North portion and an East portion of the second floor each have their own exit from the North end and the East end. These two areas connect at the center area to form an L. The only exits from the second floor are located at the ends on the North and East and then where they meet in the center.

The East portion holds the licensed patients for the hospital and is located inside the 2-hour barrier. The North portion is for outpatient therapy only and is not a part of the licensed bed count. At this time, nine patients were located in the licensed area of the hospital second floor and one out patient was in the north portion. The State Agency Supervisor was contacted and informed on the observations to this point. After discussing the findings with the Supervisor, it was determined that an Immediate Jeopardy was to be placed on the facility.

The construction area was then surveyed in order to determine what needed to take place to abate the Immediate Jeopardy. It was observed that only minor cosmetic removal and deconstruction had taken place i.e. wall paper, doors, smoke detectors removed. This enabled the construction company to have the corridor cleaned up and the temporary walls removed, doors reinstalled, and the smoke detectors replaced. The head contractor with the construction company, the Manager, Maintenance and Facilities and Maintenance Tech A then contacted the fire alarm company and ensured that the system was fully functional. The main fire alarm panel trouble signals were all clear. The immediate Jeopardy was abated at 3:37 PM.

Review of the following NFPA Standard revealed: Buildings, or portions of buildings, shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place. 2012 NFPA 101, 4.6.10.1*

During the survey on July 5, 2017 at approximately 11:20 AM it is observed that the North portion of the second floor has construction walls obstructing the exit egress. An Immediate Jeopardy was placed on the facility for this deficiency and it was abated by the walls being removed at 3:37 PM.

Based on observation and staff interview, the facility failed to provide an unobstructed corridor. This deficient practice of not providing an unobstructed corridor will prevent speedy exiting. The deficient practice affects 36 residents in 2 of 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the survey on July 5 and 6, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

1. On July 6, 2017 at 9:43 AM the North exit corridor on the 3rd floor is obstructed by physical therapy weights, crates, fan, radio, and stabilizing apparatus.

2. On July 5, 2017 at approximately 11:20AM the North exit corridors on the second floor have been eliminated by construction walls.
These walls prevent staff and patients from continuing down the corridor to the exit.

The Manager, Maintenance and Facilities was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:

(1) The door leaves shall unlock in the direction of egress upon actuation of one of the following:

(a) Approved, supervised automatic sprinkler system in accordance with Section 9.7

(b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6

(c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6

(2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.

(3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:

(a) The force shall not be required to exceed 15 lbf (67 N).

(b) The force shall not be required to be continuously applied for more than 3 seconds.

(c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening.

(d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.

(4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follow shall be located on the door leaf adjacent to the release device in the direction of egress:

PUSH UNTILALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

(5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. 2012 NFPA 101, 7.2.1.6.1.1

During the survey on July 5, 2017 at approximately 11:20 AM it is observed that the North portion of the second floor has construction walls obstructing the exit egress. This obstruction creates a dead-end corridor of 176 ft. An Immediate Jeopardy was placed on the facility for this deficiency and it was abated by the walls being removed at 3:37 PM.

Based on observation and staff interview, the facility fails to provide corridors that lead to exit egress. The deficient practice creates a dead-end corridor and prevents speedy exiting of staff and residents. This affects 18 residents in 1 of 12 smoke zones. The facility has a capacity of 58 with a census of 21.

During the survey on July 5 and 6, 2017 between the hours of 9:00AM and 4:00PM the following is observed:

1. On July 5th, 2017 at approximately 11:20 AM the construction project taking place on the North end of the second floor has created a dead-end corridor of 176 ft. One corridor is terminated by a wall constructed of metal studs and dry wall while the second corridor is terminated by a construction wall of metal studs and dry wall with a 36" non-rated door that leads directly into a construction zone.

The Manager, Maintenance and Facilities was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Existing dead-end corridors not exceeding 30 ft (9.1 m) shall be permitted. Existing dead-end corridors exceeding 30 ft (9.1 m) shall be permitted to continue in use if it is impractical and unfeasible to alter them. 2012 NFPA 101, 19.2.5.2

Based on observation and staff interview, the facility is not providing a clean kitchen exhaust hood that is in compliance with NFPA 96. Failure to provide clean filters hood and grease tray has the potential to affect all staff and visitors in 1 of 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the survey on July 5 and 6, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

1. On July 6, 2017 at 11:25 AM the kitchen hood has a buildup of grease around the grill area.
2. On July 5, 2017, no hood cleaning records are available.
3. On July 6, 2017 at 11:26 AM the hood suppression system nozzles do not have the protective caps in place.


The Manager, Maintenance and Facilities was present and acknowledged the findings.


Review of the following NFPA Standard revealed: Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.3

During the record review on July 6, 2017 at approximately 2:15PM it is revealed that the annual fire alarm inspection testing documentation is being performed in-house and the form does not include all the required NFPA information. The information available shows that various portions of the system are being tested every month over a 12 month period. An Immediate Jeopardy was placed on the facility for this deficiency and it was abated by the start of a Fire watch at 2:30 PM.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as required by NFPA 72. The failure to maintain the fire alarm system fails to ensure reliability of the alarm system in the event of an emergency, affecting all residents in all 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the survey on July 5, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

1. The fire alarm system is in trouble status. Smoke detectors have been removed from the North end of the building on the 2nd floor where a construction project has started.

2. Fire alarm testing is not being performed on an annual basis.


The Manager, Maintenance and Facilities was present and acknowledged the findings.


Review of the following NFPA Standard revealed: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. 2012 NFPA 101, 9.6.1.3

Review of the following NFPA Standard revealed: A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency( ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)
2010 NFPA 72, 14.6.2.4

During the record review on July 6, 2017 at approximately 2:20PM it is revealed that the sprinkler system annual testing was being performed in house. The documentation stated that a walkthrough had been performed and that no deficiencies were found. No other records or information was available for the system or that any physical tests were performed. An Immediate Jeopardy was placed on the facility for this deficiency and it was abated by the start of a Fire watch at 2:30 PM.

Based on record review and staff interview, the facility failed to assure that the sprinkler system is tested and installed in accordance with NFPA 13 and 25. This deficient practice fails to ensure that the sprinkler system will operate properly in the event of a fire, affecting all residents in all 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the record review on July 5, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

1.No quarterly sprinkler system testing documentation is available for the 4th quarter of 2016 and the 1st and 2nd quarters of 2017.

2. Sprinkler system testing is not being performed on an annual basis.



The Manager, Maintenance and Facilities was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height
2012 NFPA 101, 9.7.1.1

Review of the following NFPA Standard revealed: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard
for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2012 NFPA 101, 9.7.5

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk of fire, affecting all residents in all 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the record review on July 6, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

1. No documentation for the maintenance and testing of the fusible link fire dampers was available during the survey. No records were available to show if the fire dampers have been tested since the bulidings construction.

The Manager, Maintenance and Facilities was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Air-Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.1
Review of the following NFPA Standard revealed: Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2012 NFPA 90A, 5.4.8.1
Review of the following NFPA Standard revealed: The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. 2010 NFPA 80, 19.4.1.1
Review of the following NFPA Standard revealed: If the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating. 2010 NFPA 80, 19.4.8.1

Based on record review and staff interview, the facility is not conducting fire drills as required and properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all residents in all 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the record review on July 6, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

1. No fire drills were performed for the first shift during the second quarter of 2017.
2. No fire drills were performed for the third shift during the first and second quarters of 2017.
3. No signature sheets were available showing all participants for the January 2017 and the July 2016 drills.
4. The fire drill forms do not indicate any information regarding the transmission of fire alarms.
5. No scenarios are documented for the drills performed in August and November of 2016


The Maintenance Director and Administrator were present and acknowledged the findings.

Review of the following NFPA Standard revealed: The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1. A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center. Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. and
6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Employees of health care occupancies shall be instructed in life safety procedures and devices. 2012 NFPA 101, 19.7.1.1-8

Review of the following NFPA Standard revealed: The basic response required of staff shall include the following:

(1) Removal of all occupants directly involved with the fire Emergency

(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon staff

(3) Confinement of the effects of the fire by closing doors to isolate the fire area

(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

2012 NFPA 101, 19.7.2.1.2

Based on record review and staff interview the facility fails to provide for testing of the medical gas system. This deficient practice could adversely affect all persons using or receiving medical gases from the bulk medical gas system, affecting all patients in all 12 smoke zones. The facility has a capacity of 58 with a census of 21.

Findings include:

During the record review on July 6, 2017 between the hours of 9:00 AM and 4:00 PM the following is observed:

The medical gas testing documentation states that the following are deficient:
a. Air compressor: dryers not working.
b. Air compressor: Auto drain not working.
c. Master Alarms: No medical air dew point high alarm at either panel.
d. Master Alarms: No carbon monoxide high alarm at either panel.
e. 2nd floor LDR Post-Partum 2121-2128: Vacuum board has bad alarm panel.
f. 2nd floor LDR 2105-2120: C-Section does not have its own zone valve box.
g. 2nd floor LDR 2105-2120: C-Section does not have its own area alarm.
h. 2nd floor LDR 2105-2120: Recovery does not have its own zone valve box.
i. 2nd floor LDR 2105-2120: Recovery does not have its own area alarm.


The Manager, Maintenance and Facilities was present and acknowledged the findings.

Review of the following NFPA Standard revealed: Inspection Procedures. The facility shall be permitted to use any inspection procedure(s) or testing methods established through its own risk assessment.
Maintenance Schedules: Scheduled maintenance for equipment and procedures shall be established through the risk assessment of the facility and developed with consideration of the original equipment manufacturer recommendations and other recommendations as required by the authority having jurisdiction.
Qualifications: Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:

(1) Training and certification through the health care facility by which such persons are employed to work with specific
equipment as installed in that facility

(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel

(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers
2012 NFPA 99, 5.1.14.2.2.3-5

Review of the following NFPA Standard revealed: An annual review of bulk system capacity shall be conducted to ensure the source system has sufficient capacity.

Central supply systems for nonflammable medical gases shall conform to the following:

(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.
2012 NFPA 99, 5.1.14.4.3-4